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• .........T SAN JOAQUIN,, AfY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br /> r WERGROUND STORAGE TANK PROGRAM - FEE WORKSHEL4� <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I Rosenthal Building - Trust William little 467-1006 <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> a 24 South Adieracan Street c/o aae 467-1006 <br /> CITY STATE ZIP CODE 1 # of TANKS <br /> A Stockton I CA 95204 at SITE one <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L Rosenthal Trustc/o Bank of Stockton William little 467-1006 <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY STATEZIP CODE TYPE of APPLICATION <br /> Stockton CA 95204 (� e, installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> A XXXX )XXX XXXX XXXX )XXX $ XXXXXXXX <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If AppLicabLe) tp.— XX%% XXX% XXXX XXXX XXXX S XXXXXXXX <br /> I <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _ 1987 1988 1 1989 . 1990 1991 1992 1993 7994 1 1995 1996 1997 <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXXX XXXX S <br /> C <br /> 1 TANK PENALTY FEES ASSESSED %XXX XXXX XXXX XXXX XXXX $ <br /> I STATE SURCHARGE <br /> T G DO <br /> Y # Tanks_�, >� 1988 through 1990 (S56) 1991 through 1996 ($56) 1997 O <br /> p oo <br /> SURCHARGE FOR 1997 XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXX%XXXXXXXXX S D <br /> C PERMANENT CLOSURE (Reval or Authorized Closure-in-PLace) TANK I.O. #(s) <br /> L <br /> 0 CLOSURE FEE = hour (3 hours minimum/TANK) # TANK(s),�_ X $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.D. #(s) <br /> R g <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A g <br /> MI PLAN CHECK FEE = 578.00/hour (8 hours minimm/FACILITY) $624.00 minimum <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> A $ <br /> I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 8234.00 minimum <br /> R S <br /> f PIPING REPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = $234.00 minimum <br /> N TRANSFER FEE = S20.00 UN#UTHORIZED RELEASE EVALUATION 578.00/hr S <br /> 1 <br /> S S <br /> C C6NSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE 578.00/hr <br /> TOTAL DUE S'�� 6u <br /> FOR OFFICE USE ONLY _...._................_____.:,- .—_.___,—_.._—..._._...____.__....._...._.....__..T_—____.._.___.. <br /> -.1_._.___......___�.._..__..,.__._ <br /> j SWEEPS # COMPUTER # LOC CODE I DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> EH 23 032 (REVISED 5-27-97) <br />